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(1)

STATE OF NORTH CAROLINA

DEPARTMENT OF STATE TREASURER

STATE AND LOCAL GOVERNMENT FINANCE DIVISION

AND THE LOCAL GOVERNMENT COMMISSION

Mailing Address:

325 North Salisbury Street

Raleigh, North Carolina 27603-1385

Federal Express & Courier:

4505 Fair Meadow Lane, Suite 102

Raleigh, North Carolina 27607-6449

Telephone:

(919) 807-2350

Fax:

(919) 807-2377

APPLICATION FOR APPROVAL OF

GUARANTEED ENERGY SAVINGS CONTRACTS

(2)

APPLICATION DUE DATE

The Local Government Commission (the “LGC”) meets the first Tuesday of each

month, unless otherwise announced, to conduct its business, including the approval

of applications of units of government to incur debt. Generally, to allow adequate

review of applications, the staff of the LGC (the “staff”) requires that applications be

received no later than twenty-eight days prior to the date of the LGC meeting at

which the unit wants its application to be considered. However, in more complex

transactions the staff may require earlier submission.

Although this application form is available to interested parties by internet

access; the project and the related proposed financing should be discussed with the

staff prior to submission of an application. Before the application is accepted for

submission to the LGC a preliminary conference may be required (G.S. 159-149).

LEGISLATIVE REPORTING REQUIREMENT

State law G.S. 120 - 157.1 – 157.4 adopted and effective on June 24, 2011

requires that certain capital projects to be financed with debt in an amount

exceeding $1,000,000 be reported to the Joint Legislative Committee on Local

Government and to the Fiscal Research Division of the North Carolina General

Assembly at least 45 days before the application for debt is to be considered for

approval by the Local Government Commission. The law applies to all capital

projects to be financed by issuing debt over $1,000,000 with the exception of schools,

jails, courthouses and administrative buildings. Copies of the reporting should also

be sent to our office at the time of the filing.

(3)

STATE OF NORTH CAROLINA

DEPARTMENT OF STATE TREASURER

State and Local Government Finance Division

and the Local Government Commission

325 North Salisbury Street, Raleigh, North Carolina 27603-1385

APPLICATION FOR APPROVAL OF GUARANTEED

ENERGY SAVINGS CONTRACTS

1. Unit _____________________________________________________________ Date _______________ 2. Project Description ______________________________________________________________________ 3. Necessity _______________________________________________________________________________

4. Principal Amount to be Financed (Do not include any maintenance costs.)... $ 5. Interest to be paid during life of contract ... $ 6. Amount due throughout life of contract ... $

(i.e., amount of periodic payment times number of payments. Should also be the total of 4  5 above.)

7. Term of contract including options to renew (if any) ... ________________ 8. Qualified Provider selected _______________________________________________________________

9. The attached are furnished in support of this application:

 a. Certified copy of resolution of governing body making necessary findings and authorizing the contract.

 b. Resolution from Board of County Commissioners acknowledging this project. (for Boards of Education or Community Colleges)

 c. Publisher’s Affidavit of Notice of Request for Proposals (at least 15 days in

advance of opening). RFP posted on SEO website.

 d. Publisher’s Affidavit of Notice of Award (at least 15 days before date of

meeting).

 e. Certified copy of minutes of hearing.

 f. Evidence that two proposals were received. If not, explain.

 g. Summary of licensed architect/engineer evaluation of final proposal.

(4)

 i. Performance Bond or acceptable guarantee from Energy Services Contractor equal to 100% of total cost of guaranteed energy savings contract.

 j. Proposed financing contract.

 k. Proposed guaranteed energy savings contract with all schedules and exhibits. SEO to review and comment.

 l. Completed IRS form 8038-G (2 copies) (To be provided at loan closing).  m. Unit Attorney’s Opinion.

 n. Fee Arrangement Letters:  Special Counsel  Banker/Underwriter

 o. Notice from Electric Company/ies that dual invoices will be mailed — one to unit, one to vendor.

 p. Other: Specify __________________________________________________________________ .  q. Application fee for installment/lease purchase agreement contract. Attach check for

appropriate amount.

 $1,250 for private placement.  $12,500 for public offering.

10. Current audited financial statements have been received by Fiscal Management. Audit Reports are due October 31 each year. For units with a calendar year or fiscal year not ending on June 30, audited financial statements should be received within four months of year-end. Yes  No 

11. Unit’s Attorney ____________________________________________ Telephone _________________ Address ___________________________________________________ Fax _______________________ 12. Guaranteed Energy Savings Contract vendor ______________________________________________ Contact Person ____________________________________________ Title ______________________ Telephone _________________________________________________ Fax _______________________ 13. Financing contract/agreement with _______________________________________________________ Contact Person ____________________________________________ Title ______________________ Telephone _________________________________________________ Fax _______________________ 14. Consulting Firm ________________________________________________________________________

(Architect or Engineer)

Contact Person ____________________________________________ Title ______________________ Telephone _________________________________________________ Fax _______________________ 15. Unit’s Authorized Agent _________________________________________________________________ Title _______________________ Telephone ___________________ Fax _______________________ This application and supporting documents are deemed to be true and accurate to the best of my knowledge and belief.

______________________________________________ ___________________________________

Signature of Authorized Agent Date

(5)

LGC-108F

STATE OF NORTH CAROLINA

DEPARTMENT OF STATE TREASURER

State and Local Government Finance Division

and the Local Government Commission

325 North Salisbury Street, Raleigh, North Carolina 27603-1385

GUARANTEED ENERGY SAVINGS CONTRACTS

ESTIMATES OF PROJECT COSTS AND ENERGY SAVINGS

Project Costs

Proposal Evaluation Costs $ ____________________ Design and Engineering ____________________ Construction ____________________ Installation ____________________ Modification/Remodeling ____________________ Maintenance ____________________ Repairs ____________________ Training ____________________ Legal ____________________ Other ____________________

Total Estimated Project Costs as of ____________________________ $ ____________________

(date)

Total Coat of Performance Verification $ ____________________ Total Financing Cost (Interest expense, administrative costs) $ ____________________ Total Estimated Project Costs, Performance Verification Cost

and Financing Cost $ Total Estimated Energy Savings over Contract term $

I certify that these are the estimated project costs and energy savings projected by ______________ _____________________________________ qualified provider, selected by the local governmental unit.

____________________________________________________ Signature

____________________________________________________ (SEAL) Typed or Printed Name

(6)

[FORM RESOLUTION]

GUARANTEED ENERGY SAVINGS CONTRACTS

RESOLUTION AUTHORIZING THE FILING OF AN APPLICATION FOR APPROVAL OF A GUARANTEED ENERGY SAVINGS CONTRACT AUTHORIZED

BY NORTH CAROLINA GENERAL STATUTE 143-64.17C

WHEREAS, the [local government unit] of ____________________, North Carolina desires to enter into a Guaranteed Energy Savings Contract (the “Contract”) to [install energy conservation measures] (the “Project”) so as to reduce energy consumption and/or energy-related operating costs; and

WHEREAS, the [local government unit] desires to finance the Project by the use of an installment contract authorized under North Carolina General Statute 160A, Article 3, Section 20; and

WHEREAS, the term of the Contract does not exceed twelve years from the date of the installation and acceptance by the local government unit of the energy conservation measures provided under the Contract; and

WHEREAS, the energy savings resulting from the performance of the Contract will equal or exceed the total cost of the Contract pursuant to an evaluation performed by [a licensed architect or engineer] on behalf of [the local government unit]; and

WHEREAS, the energy conservation measures to be installed under the Contract are for an existing building; and

WHEREAS, findings of fact by this governing body must be presented to enable the North Carolina Local Government Commission to make its findings of fact set forth in North Carolina General Statute 159, Article 8, Section 151 prior to approval of the proposed contract;

NOW, THEREFORE BE IT RESOLVED that the [local government unit], meeting in [regular/special] session on the ________ day of _______________, 20_____, make the following findings of fact:

1. The proposed Contract is necessary or expedient because [state facts supporting such conclusion].

2. The proposed Contract is preferable to a bond issue for the same purpose because [state the reasons and justifications for choosing the contract method of financing rather than a nonvoted general obligation bond issue or a voted general obligation bond issue].

3. The sums to fall due under the Contract are adequate and not excessive for the proposed purpose because the energy savings over the period of the Contract are guaranteed to equal or exceed the total costs of the improvements.

(7)

5. An increase in taxes is not necessary since the guaranteed energy savings equal or exceed the sums to fall due under the Contract.

OR

The initial increase in taxes necessary to meet the sums to fall due under the proposed Contract will be _________ cents per $100 valuation and is not deemed to be excessive. Given the guarantee of energy savings equaling or exceeding total costs, such an increase in taxes is expected to be recaptured over the term of the Contract.

6. The [local government unit] is not in default in any of its debt service obligations.

7. The attorney for [local government unit] has rendered an opinion that the proposed project is authorized by law and is a purpose for which public funds may be expended pursuant to the Constitution and laws of North Carolina.

NOW, THEREFORE, BE IT FURTHER RESOLVED that the [Authorized representative] is hereby authorized to act on behalf of [the local government unit] in filing an application with the North Carolina Local Government Commission for approval of the Project and the proposed Guaranteed Energy Savings Contract and other actions not inconsistent with this resolution.

This resolution is effective upon its adoption this ________ day of _______________, 20_____. The motion to adopt this resolution was made by [Commissioner] ____________________, seconded by [Commissioner] ____________________, and passed by a vote of ________ to ________.

[Chairman of Board of Education] ATTEST:

____________________________________________ [Clerk/Secretary]

This is to certify that this is a true and accurate copy of Resolution _________, adopted by the [local government unit] Board of Education on the ________ day of _______________, 20_____.

____________________________________________ ____________________________

(8)

[FORM RESOLUTION]

RESOLUTION ACKNOWLEDGING THE EXECUTION AND DELIVERY BY THE ___________________________ COUNTY BOARD OF EDUCATION OF A GUARANTEED ENERGY SAVINGS CONTRACT

BE IT RESOLVED by the Board of Commissioners (the “Board”) of the County of ____________________, North Carolina (the “County”) as follows:

1. The Board hereby finds, determines and acknowledges that:

(a) the _______________________________ County Board of Education (the “School Board”) plans to enter into a $________________ guaranteed energy savings contract pursuant to G.S. 143-64.17 et. seq. for the purpose of providing certain energy conservation measures authorized thereby (the “Project”) so as to reduce energy consumption and/or energy-related operating costs;

(b) the School Board intends to finance the Project by entering into an installment contract (the “Contract”) pursuant to G.S. 143-64.17C and G.S. 160A-20, as amended;

(c) the energy savings resulting from the Project are expected to equal or exceed the total costs payable under the Contract as shown in an evaluation performed by a [licensed architect or engineer] on behalf of the School Board;

(d) the payments under the Contract are not expected to require any additional appropriations to be made to the School Board nor any increase in taxes; and

(e) the Board does not intend to reduce appropriations to the School Board based upon a reduction of energy costs in a manner that would inhibit the ability of the School Board to make the payments under the Contract, provided that the County is not bound in any manner to appropriate funds to the School Board in amount sufficient for the School Board to make such payments.

2. Whereas, the Board of Commissioners has, pursuant to G.S. 115C-429(b), allocated part or all of its school capital outlay appropriation by purpose, function or project as defined in the uniform budget format, the Board, pursuant to G.S. 115C-433(b), also approves an amendment to the budget that increases expenditures from the capital outlay fund for the Project in the amount of $_________________.

(Insert paragraph #2 in the Resolution, only if required by G.S. 115C-433(b).) 3. This resolution shall take effect upon its passage.

[SEAL] Chairman, Board of Commissioners

of the County of ________________________________ I DO HEREBY CERTIFY that this is a true and correct copy of the resolution duly adopted by the Board of Commissioners of the County of ___________________ at a [regular/special] meeting held on ______________________, 20_____.

_______________________________

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